The Role of the Anesthesiologist in Management of Obstetric Hemorrhage
Section snippets
Unexpected Obstetric Hemorrhage
The clinical scenario we are discussing in this section is when the anesthesiologist is called to see and assume care for a patient with an unexpectedly high blood loss after a vaginal delivery. The approach and issues are similar when the bleeding occurs during an expected routine cesarean delivery, but during a cesarean delivery, the anesthesiologist is already present, usually more prepared and certainly more familiar with the patient. It is our experience that more confusion,
High-Risk: “Expected” Hemorrhage
The advent of ultrasound and other advances in imaging have resulted in improved and increased antepartum diagnosis of a variety of conditions associated with increased risk for bleeding, including placenta previa, placenta accreta, vasa previa, etc.15 Placenta accreta (and especially increta/percreta) ranks chief among these conditions in risk for massive, sometimes uncontrollable blood loss. Ninety percent of patients with placenta percreta will lose more than 3000 mL at cesarean
Transfusion Therapy
Regardless of the mode of anesthesia used for these cases, it is prudent to have sufficient blood products immediately available. All blood components are screened (checked) by two people to confirm that products are correctly paired to the patient before the patient is brought to the operating room. Our standard practice for cases with large anticipated blood loss (eg, suspected placenta percreta) is to keep 20 U of cross-matched PRBCs and 20 U of FFP in a refrigerator or cooler in the OR
Cell Salvage in Obstetrics
There are many reasons to consider or favor cell salvage and reinfusion techniques in the case of major hemorrhage. The cost of cell salvage is less than that of obtaining and processing homologous (blood bank) blood; there is no risk of incompatible transfusion or similar transfusion reactions; the risk of infection is reduced; and the blood available may bridge those periods when the blood bank delivery of product “falls behind” the blood loss. Cell salvage may be particularly useful in cases
Conclusion
The anesthesiologist should play a key role in the management of obstetric hemorrhage. As with almost all medical and surgical crises or emergencies, the principles of preparation and planning when possible, early notification when necessary, and good communication and teamwork at all times are the keys to successful outcomes.
References (52)
James Blundell: The first transfusion of human blood
Resuscitation
(2002)- et al.
Discrepancy between laboratory determination and visual estimation of blood loss during normal delivery
Eur J Obstet Gynecol Reprod Biol
(1991) - et al.
Haemodynamic effects of oxytocin given as i.v. bolus or infusion on women undergoing Caesarean section
Br J Anaesth
(2007) - et al.
Signs of myocardial ischaemia after injection of oxytocin: A randomized double-blind comparison of oxytocin and methylergometrine during Caesarean section
Br J Anaesth
(2008) - et al.
Interventional radiology in women with suspected placenta accreta undergoing caesarean section
Int J Obstet Anesth
(2008) - et al.
Postpartum myocardial infarction induced by methergine
Am J Emerg Med
(1998) - et al.
Caesarean section for placenta praevia: A retrospective study of anaesthetic management
Br J Anaesth
(2000) - et al.
Antenatal erythropoietin and intra-operative cell salvage in a Jehovah's witness with placenta praevia
Br J Obstet Gynaecol
(2003) - et al.
[Evaluation of the blood quality collected by cell-saver during cesarean section]
Ann Fr Anesth Reanim
(1996) - et al.
Contamination of salvaged maternal blood by amniotic fluid and fetal red cells during elective Caesarean section
Br J Anaesth
(2008)
Cell salvage during cesarean delivery: Is it safe and valuable? Maybe, maybe not!
Int J Obstet Anesth
Cell salvage in obstetrics
Int J Obstet Anesth
Blood conservation techniques in obstetrics: A UK perspective
Int J Obstet Anesth
Use of recombinant activated factor VII in massive postpartum haemorrhage
Eur J Obstet Gynecol Reprod Biol
Normovolemic hemodilution before cesarean hysterectomy for placenta percreta
Obstet Gynecol
Acute normovolemic hemodilution, intraoperative cell salvage and PulseCO hemodynamic monitoring in a Jehovah's Witness with placenta percreta
Int J Obstet Anesth
The role of intraosseous vascular access in the out-of-hospital environment (resource document to NAEMSP position statement)
Prehosp Emerg Care
Estimation of blood loss after cesarean section and vaginal delivery has low validity with a tendency to exaggeration
Acta Obstet Gynecol Scand
Improved accuracy of postpartum blood loss estimation as assessed by simulation
Acta Obstet Gynecol Scand
Management of the obstetrical patient with hemorrhage due to an acute or subacute defibrination syndrome
Blood
Oxytocin requirements at elective cesarean delivery: A dose-finding study
Obstet Gynecol
Minimum oxytocin dose requirement after cesarean delivery for labor arrest
Obstet Gynecol
Uterine contraction and physiological mechanisms of modulation
Am J Physiol
Diagnosis and treatment of peripartum bleeding
J Perinat Med
Deaths associated with anaesthesia
The human G-protein beta3 subunit C825T polymorphism is associated with coronary artery vasoconstriction
Eur Heart J
Cited by (25)
Obstetric Hemorrhage in the Rural Emergency Department: Rapid Response
2017, Journal of Emergency NursingCitation Excerpt :The family member or patient will report blood loss at home that is difficult to estimate. In the hospital setting, visually estimated blood loss recently has been cited as lacking in accuracy.13–15 Recommendations are to move to quantitative blood loss methods to improve accuracy and provide an earlier alert of excessive blood loss.16
Anesthetic management as a risk factor for postpartum hemorrhage after cesarean deliveries
2011, American Journal of Obstetrics and GynecologyCitation Excerpt :Spinal/epidural anesthesia has been contraindicated relatively for women who are at risk of major hemorrhage because of concerns about hemodynamic instability and the need to resuscitate an awake patient. General anesthesia with a secured airway is still recommended to facilitate preparation for rapid massive transfusion and potential complications, which include hysterectomy.28 However, as noted by previous studies, spinal/epidural anesthesia has not been associated with increased blood loss29 and perhaps should not be contraindicated for patients with CS who are at increased risk for PPH.
Red code survey in five health care institutions in Bogotá
2010, Revista Colombiana de AnestesiologiaMaternal haemorrhage
2009, British Journal of AnaesthesiaCitation Excerpt :rFVII has also been successfully used to prevent or control bleeding in several other conditions including thrombocytopenia, platelet function disorders, impaired liver function, and extensive surgery and severe trauma with massive bleeding.10 Although no randomized controlled studies have been published on the use of FVIIa in PPH, case reports have suggested great efficacy in helping to control massive obstetric bleeding.23 Consideration for the use of rFVII in PPH must take into account efficacy, side-effects including increased risk of thromboembolism, and costs of rFVII vs other treatment.53
Peripartum Haemorrhage, Diagnosis and TherapyGuideline of the DGGG, OEGGG and SGGG (S2k, AWMF Registry No. 015-063, August 2022)
2023, Geburtshilfe und FrauenheilkundeCase report: Massive obstetric hemorrhage
2022, Revista Chilena de Anestesia